Daily Health Attestation
Complete this form each afternoon before you come to Etzim. If you are over 18 you can fill it out for yourself, otherwise a parent or guardian must complete it.
Today's Date *
MM
/
DD
/
YYYY
Teen's First Name *
Teen's Last Name *
Within the last 14 days, has your child or anyone in your household had close contact with a COVID-19 positive individual? *
If the answer to this question is "yes," please do not come to Etzim today.
Has your child or a member of your household experienced any of the following symptoms in the past 24 hours? *
If your answer to any of these symptoms is "yes," please do not come to Etzim today.
Yes
No
Fever of 100.4℉ or higher
Cough
Sore throat
Difficulty breathing
Gastrointestinal symptoms (diarrhea, nausea, vomiting)
New loss of smell/taste
New muscle aches
Have you or a member of your household experienced any of the following symptoms in the past 24 hours? *
We are referring to symptoms that cannot be attributed to something else. If, for example, you have a runny nose due to allergies, do not say "yes" for that symptom. If your answer is "yes" for ONE of the symptoms below, you may come to Etzim if you are feeling up to it. If your answer is "yes" for TWO or more of the symptoms listed below, please do not come to Etzim today.
Yes
No
Fatigue
Headache
Runny nose or congestion
Any other sign of illness
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